Q16) Unstable angina (UA) (uni book)

Definition: Unstable angina is an acute or subacute coronarogenic myocardial ischemia,

which does not lead to development of necrosis. It is classified into:

 Newly appeared angina

 Accelerating stable angina
 Angina at rest
 Early post-infarction angina upto 14 days after AMI

Pathogenesis

The destabilized atherosclerotic plaque lead to the formation of a thrombus, which

obliterates the coronary arteries partially or totally. The fibrinolytic system gets activated
and is capable of restoring the patency of the vessel but in the rest of the 20-40% critical
stenosis with/without an added spasm is responsible.

Braunwald's classification of unstable angina (book)

Clinical presentation :

- angina at rest
- less effort provokes pain
- pain propagates to more places
- pain duration is increased

NB: The destabilisation of the coronary plaque requires an urgent hospitalisation.

Hence the moment of plaque activation is important .

Diagnosis

 Any stress tests in the acute phase are prohibited (bicycle ergometer, treadmill)
 Check serum level of troponins
 ECG - ST depression
 Radioisotope scintography
 contrast CT
 positron emitted tomography (PET)
 Coronary angiography (gold standard) is combined with intracoranary
echocardiography to rule out CAD.
 unstable angina is divided into:
1. troponin (+) = indicaton of coronary angioraphy
2. troponin (-) = requires a stress test before hospital discharge and then every
6-12 months.

Treatment

UA patients are hospitalised in ICU, where they receive:

 sedation
 oxygen
 anticoagulants e.g unfractionated Heparin can be started about 1000 U/hour,
following day, low molecular weight heparin (LMWH) is given i.e. Arixtra 2.5mg/day
subcutaneoulsy.
 Nitrates can be given to abolish chest pain (but don't affect the prognosis)
 Beta blockers for CAD treatment
 Calcium channel blockers given if angina persists or spasms suspected.
 Statins also used to treat CAD
 High risk patient e.g. who are troponin (+), with persistent angina, hemodynamically
unstable, are given coronary angiography followed by revascularisation procedure
(PTCA or CABG). The rest of the patients, who have been stabilised, a stress test if
performed , if + they are referred to a cathlab for coronary angiography.